Provider Demographics
NPI:1982919114
Name:WILLIAMS, WILBERT LEE JR
Entity Type:Individual
Prefix:
First Name:WILBERT
Middle Name:LEE
Last Name:WILLIAMS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2880 HIGHWAY 190
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-3254
Mailing Address - Country:US
Mailing Address - Phone:985-624-8548
Mailing Address - Fax:985-624-4872
Practice Address - Street 1:2880 HIGHWAY 190
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3254
Practice Address - Country:US
Practice Address - Phone:985-624-8548
Practice Address - Fax:985-624-4872
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10398183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist